HOW TO IMPLEMENT SBIRT: PROCESSES, TIPS, AND EXAMPLES …

Megan A. O’Grady, PhD Research Scientist

Associate Director of Health Services Research

The National Center on Addiction and Substance Abuse (CASA)

June 28, 2017

HOW TO IMPLEMENT SBIRT:

PROCESSES, TIPS, AND EXAMPLES

FROM THE FIELD

Integrating Primary and Behavioral Health Care Through the Lens of Prevention Conference Fort Worth, Texas

© National Center on Addiction and Substance Abuse 2016

Collaborators and Funders

National Center on Addiction and Substance Abuse (CASA) Charles Neighbors, MBA, PhD; Kristen Pappacena, MA; Cherine Akkari, MS;

Camila Bernal, MPH; Jon Morgenstern, PhD

Northwell Health Joe Conigliaro, MD, MPH; Jon Morgenstern, PhD; Nancy Kwon, MD, MPA;

Sandeep Kapoor, MD, Fred Muench, PhD

Montefiore Health System Henry Chung, MD; Chinazo Cunningham, MD

New York State Office of Alcoholism and Substance Abuse

Services (OASAS)

Substance Abuse and Mental Health Association (SAMHSA) Grant #: 5U79TI025102 received by The New York State Office of Alcoholism

and Substance Abuse Services (NYSBIRT-II)

New York State Health Foundation


Overview

• SBIRT Basics

• Barriers and Facilitators of Implementation

• Practical Implementation Tools, Tips and

Examples

• Putting It All Together

• Sustainability

• Other Practical Advice


Screening, Brief Intervention, and

Referral to Treatment (SBIRT) Basics

SBIRT is a structured approach used in a variety of

settings to:

1) Identify and provide prevention and early

intervention for persons who use substances in ways

that increase their risk of physical health, mental

health, or social problems

2) Provide linkages to specialty treatment for people

with suspected or diagnosed substance use disorders


Screening, Brief Intervention, and

Referral to Treatment (SBIRT) Basics

Component Goal

Screening • Quickly assess severity of substance use w/ validated tool

• Identify appropriate level of intervention

Brief Intervention

• Provide feedback • Increase insight and awareness regarding substance

use and motivation to change • Negotiate and set goals

Referral to Treatment

• For those identified as needing more extensive care • Linkage to specialty provider for further assessment,

diagnosis, and intake at proper level of care


Implementation of SBIRT

• Large-scale implementation and maintenance of

SBIRT in healthcare settings has been limited,

despite:

• evidence for effectiveness in reducing substance use

and/or related consequences in certain contexts and

circumstances (e.g., Alvarez-Bueno et al., 2015)

• government and policy organizations promoting

widespread adoption (e.g., SAMHSA, USPSTF, ASCOT, CDC)

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SBIRT is not being done routinely………

7


Barriers and Facilitators of

SBIRT Implementation

• Occur at various levels (e.g., Johnson et al., 2011; Nilsen, 2010)

• Staff: attitudes, training, and skills

• Patient: reluctance to discuss, characteristics

• Organizational: support, resources and buy-in

• Site: workflow, competing demands, resources, space

• State/federal policy: billing, exchange of information

• Affect success of intervention implementation as noted by

implementation science models (e.g., CFIR, Damschroder et al., 2009; Williams et

al., 2011)

• More intensive efforts to address barriers during

implementation are more successful (e.g., Nilsen et al., 2006; Zatzick et al.,

2014)

8


The SBIRT program matrix: A conceptual framework

for program implementation and evaluation (2017)

Del Boca et al. 2017; Addiction pages 12-22, 10 JAN 2017 DOI: 10.1111/add.13656 http://onlinelibrary.wiley.com/doi/10.1111/add.13656/full#add13656-fig-0001

http://onlinelibrary.wiley.com/doi/10.1111/add.13656/full#add13656-fig-0001







Practical Implementation Solutions

• Tailoring your implementation strategy based on site specific: (Baker, et al. 2010)

• barriers and facilitators

• workflow

• Borrowing tools from quality improvement methods: (Langley, Nolan, Nolan, Norman & Provost, 1996)

• emphasis on systems change

rather than individuals

• champions and process change teams

• data driven monitoring and evaluation

• rapid cycle change processes


Evidence for Practical Solutions

Recent large evaluation suggests that the following facilitate

SBIRT implementation (Vendetti et al. 2017):

• SBIRT champions • Facilitate buy-in by practitioners and other site staff

• Facilitate inter-organizational communication and collaboration

• Adopting specialist models instead of using medical

generalists to deliver services

• Quality assurance: training, data monitoring, feedback

• Allowing adequate start-up time to develop organizational

linkages, promote buy-in, and conduct training

11


Decisions to Make • Screening: Who performs? Frequency? All patients? What

tools? Protocol?

• Brief Intervention: Who performs? Format? Protocol?

• Referral: Who performs? Where to? Protocol?

• Billing: Will you bill? How to document? Are the systems in place? Protocol?

• Performance Monitoring and Evaluation: Who does this? How is it reported? Protocol?

• Informing all staff: How will all staff at the site be informed of this new initiative? On an ongoing basis?

• Training: Who will train staff? Who will receive training? Ongoing supervision and training?

Patient enters the clinic,

registers, and is roomed

Patient is pre-screened by MAs after vital signs

Responses from pre-screen are documented into EMR

*Positive screen will elicit an ICON to the Health

Coach.

*Negative screens will be tracked

Health Coach will perform full screen and

provide brief intervention, brief

treatment or referral to treatment for positive

full screens

Health Coach will present to treating

MD/NP/RN as needed

Interaction is documented with the EMR

Example Primary Care Workflow


Example Implementation Roll-Out

6-4months 3months 2months 1month Pilot Services

Gauge Interest and get buy-in of Leadership

Hire specialist

Training of On-Site Clinical

Frontline Staff

Finalize Workflow, Logistics, EMR needs/changes

Train specialist

L

I

V

E

Initial Planning with site staff


Implementation Tools and Processes

Tool 1: Champions & Change Teams

Tool 2: Assessing Barriers

Tool 3: Getting to Know the Site

Tool 4: Plan, Do, Study, Act Cycles

Tool 5: Performance Monitoring

and Evaluation


Tool 1: Champions and Change Teams

What is a champion?

• Takes special interest and action in the SBIRT project

• Leads and supports change efforts

• Promotes the benefits of SBIRT

• Helps change the norms of the site

Champion should be someone who:

• is a member of the front line medical or clinical team

• has insight into the site work environment

• is supportive of SBIRT implementation at their site

• is well respected by leadership and peers

• is an enthusiastic problem solver



The champion’s typical responsibilities:

• Speak enthusiastically in support of the program

• Leads or supports implementation and ongoing program monitoring

• Be a model for good performance of SBIRT protocols

• Elicit feedback and heighten morale for SBIRT

• Address site staff questions, feedback, and concerns

• Assist in quality improvement cycles



Change team:

• Group of individuals with knowledge of the system needing changing and/or improving

• Could be a broad spectrum of employee

• Provides support and buy-in for changes being implemented

• Diverse perspectives and levels of education/expertise

• Creative, open-minded, problem solvers

• Formulate and implement quality improvement cycles


Tool 1: Example of primary care champion

and change team

Primary Care change team:

• Attending physician (champion)

• Office manager

• Medical assistant

• LPN who oversees medical assistants

• Behavioral health specialist


Tool 1: Champion and Change Team Tips

• Make sure the site understands what an SBIRT champion is and what their role will be before they are selected/volunteer

• Provide a quick reference guide for all champions so they know:

• Basics about SBIRT, their role/duties, program details, FAQs, what other staff roles are

• Champions at multiple levels/position types could be useful

• Can be fluid: change team members can change based on needs


Tools and Processes






and Evaluation



• Conduct an assessment specific to the site

• Worksheet is included in the CASA implementation manual

• Factors to assess:

• Patient (age, insurance, language)

• Staff (attitudes, skills, training, interest)

• Site (time constraints, staffing, training needs)

• Organization (buy-in, resources, referral sources, EMR,

data management)


Tool 2: Tips for Assessing Barriers

• Goal is to:

• determine what barriers most need to be addressed during implementation via training, resource allocation, model adaptation

• how the SBIRT components need to be tailored to the site

• Utilize change team members to gather information

• Good reason for diverse change team

• Conduct needs assessments, surveys, and/or interviews if needed to be thorough


Tools and Processes






and Evaluation



What is the current workflow?

• Shadowing a key staff member

• Observing the site

• Conduct a walk-through as a patient

Process mapping:

• Visualize the current workflow of the site without SBIRT

• Fosters discussion about where SBIRT could fit

• Create additional process map with SBIRT components plugged in


Tool 3: Example of Process Map


Tool 3: Tips for Getting to Know the Site

• Use objective methods to determine current workflow so

that you don’t overlook important factors

• Shadowing, walk-throughs

• Put all options on table when thinking about how/where

SBIRT components can fit


Tools and Processes






and Evaluation



• Mini experiments used to test

new SBIRT processes

or changes to existing

processes

• Conducted quickly over a

short period of time

• Determine whether new

process works or new

solution is needed

(Langley et al., 1996)


Tool 4: PDSA Example

Problem identified: Is having LPNs conduct patient screening using the AUDIT-C as part of vital signs feasible?

Plan: 1 LPN will screen patients using AUDIT-C on Saturdays for 1 month

Do: 1) LPN conducts screening every Saturday for 1 month 2) LPN records screening in EMR

Study: 1) EMR data is examined to determine how many patients were screened and 80% of patients were screened during allotted timeframe 2) interview conducted with LPN who described the process as feasible, with little added time to workflow and little patient pushback

Act: Screening will be expanded to additional LPNs at the site


Tool 4: PDSA Example

Problem identified: Patient pre-screens being missed because residents were bringing patients to the room instead of Medical Office Assistant who was trained to do pre-screen. Will training residents increase pre-screen completion rates from 60% to 80%?

Plan: Champion trains residents to conduct pre-screens

Do: 1) Residents start conducting pre-screens 2) Data on pre-screen completion rates collected

Study: Examine pre-screen completion rate before and after residents were trained, completion rate increases by 20%

Act: Improvement big enough, training of residents will continue with each new resident group


Tool 4: Tips for PDSAs

• Keep them short

• Don’t discount ideas that may at first not sound feasible

• Seek feedback from front-line staff and make sure

change team is involved

• Carefully plan for data collection so you know if the new

process was successful


Tools and Processes






and Evaluation


Tool 5: Performance Monitoring and Evaluation

• Important to use data to monitor program performance and

progress

• Before implementation, the team should determine:

• what metrics will be used

• who will collect, manage, and analyze data

• how and at what frequency will results be communicated

• Data can help to drive decisions and inform when PDSA

cycles may be needed



• Examples of data points to be collected:

• Total eligible patients/clients to be screened

• % receiving screening

• % with positive screen

• % of eligible receiving brief intervention

• % of eligible receiving referral

• % patients receiving follow up


Tool 5: Example NYSBIRT-II Performance Monitoring Data

Patient Census

155,716

Pre-Screen Completed

67% (104,357 )

Pre-Screen Deferred*

10% (14,714) *illness, refusal, intox

Pre-Screen Missed

23% (36,645 )

Positive

11% (11,673) Incomplete Full Screen*

35% (4,009) *illness, refusal, missed

Negative

89% (92,209)

Full Screen Completed

65% (7,664)

BI-Only

78% (2,968)

Full Screen Negative

51% (3,874)

Full Screen Positive

49% (3,790)

BI + Referral

20% (729)

Refused

2% (82)



Other ways to understand implementation:

• Surveys of site staff to understand attitudes,

behaviors and favorability toward

implementation

• Interviews with site staff to understand the

above in more depth


Tool 5: Example NYSBIRT-II Evaluation Results

“I wish there was a way to see how we’re helping people. I would like to know some follow-up results for patients. How they are doing, if they entered treatment, etc.” -RN, Emergency Medicine

“Until we worked out some of the workflows, and got things worked out, I was worried. I was really worried at first and it did take a few minutes away from my time. But it has changed over time and I now see the value.” -Attending MD, Internal Medicine


Tool 5: Example Preliminary Evaluation Results

• Six months after receiving brief intervention, patients are showing positive changes:

• decreased days of alcohol use by 40%

• decreased days of drug use by 30%

• more patients were employed and living in permanent housing

• less patients reported experiencing negative social and health consequences related to their substance use

• ¼ of those referred enter treatment within 90 days


Putting It All Together

Building Champions and Change Teams

Assess setting and tailor protocols

Process Improvement

Performance Monitoring

Training


Other Practical Considerations

• Training: necessary but much more than training

is needed

• Technology: EMR, tablets, web-based

• Site type: patient population, staff differences

• Model selection: health educator vs. team-based

• Billing and reimbursement

• Time needed to roll out in a site


Post-Implementation: Ongoing Needs

Ongoing Performance Monitoring

Evaluation

Ongoing Training/fidelity

monitoring PDSA

Champion Building

Maintenance and Sustainability


Sustainability

Recent evaluation of large-scale sustainability (Singh et al., 2017)

• Champions: continued need to gain buy-in via presentations, trainings, workshops, billing

• Systemic changes: intra and inter-agency relationships must be maintained

• Staffing: coordinating with other behavioral health screens, turnover, funding

• Easily modified program model and structure

• Funding: limited reimbursement levels and capitated payments; billing concerns by patients


Lessons Learned

• Team-Based approach necessary for: • Implementation • Delivery of Care • Maintenance of practice

• Closing loops of feedback from front-line stakeholders will go a long way

• Champions needed at different levels

• Efforts do not stop at implementation—ongoing attention needed

• Fidelity to screening and BI practices challenging

• Data collection/monitoring essential


Resources

CASA Implementation Manual: https://www.centeronaddiction.org/sites/default/files/files/An-SBIRT-implementation-and-process-change-manual-for-practitioners.pdf

CDC Implementation Guide for Primary Care:

http://www.cdc.gov/ncbddd/fasd/documents/alcoholsbiimplementationguide.pdf

SAMHSA TAP 33: Systems Level Implementation of SBIRT:

http://store.samhsa.gov/shin/content//SMA13-4741/TAP33.pdf NYS Office of Alcoholism and Substance Abuse SBIRT:

http://www.oasas.ny.gov/AdMed/sbirt/ NYSBIRT Intro to SBIRT Video:

https://www.youtube.com/watch?v=ab6BInLjP-c&index=1&list=PLNIxVjyAHXCPOzPqn6mNV9d4DRJ7E37e8

https://www.centeronaddiction.org/sites/default/files/files/An-SBIRT-implementation-and-process-change-manual-for-practitioners.pdf





















http://store.samhsa.gov/shin/content/SMA13-4741/TAP33.pdf





http://www.oasas.ny.gov/AdMed/sbirt/








Megan A. O’Grady, PhD Research Scientist

Associate Director of Health Services Research

The National Center on Addiction and Substance Abuse (CASA)

THANK YOU

[email protected]

http://www.centeronaddiction.org

212-841-5243

mailto:[email protected]

http://www.centeronaddiction.org/

http://www.centeronaddiction.org/


References Alvarez-Bueno, C., Rodriguez-Martin, B., Garcia-Ortiz, L., Gomez-Marcos, M.A., & Matinez-Vizcaino, V. (2015). Effectiveness of brief interventions in primary health care settings to decrease alcohol consumption by adult non-dependent drinkers: a systematic review of systematic reviews. Preventative Medicine, 76, SS33-38.

Baker, R., Comosso-Stefinovic, J., Gillies, C., Shaw, E.J., Cheater, F., et al. (2010). Tailored interventions to overcome barriers to change: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 3, 1-63.

Damschroder, L., Aron, D., Keith, R., Kirsh, S., Alexander, J., & Lowery, J. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science, 4:50.

Del Boca, F.K., McRee, B., Vendetti, J., & Damon, D. (2017). The SBIRT program matrix: a conceptual framework for program implementation and evaluation. Addiction, 112, S2, 12-22.

Johnson, M., Jackson, R., Guillaume, L., Meier, P., & Goyder, E. (2011). Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. Journal of Public Health, 33, 412-421.

Langley, G.J., Nolan, K.M., Nolan, T.W., Norman, C.L., & Provost, L.P. (1996). The Improvement Guide. San Francisco: Jossey-Bass.

Nilsen, P. (2010). Brief alcohol intervention-where to from here? Challenges remain for research and practice. Addiction, 105, 954-959.

Nilsen, P. Aalto, M., Bendtsen, P., & Seppa, K. (2006). Effectiveness of strategies to implement brief alcohol intervention in primary healthcare. Scandinavian Journal of Primary Health Care, 24, 5-15.

Singh, M., Gmyrek, A., Hernandez, A., Damon, D., & Hayashi, S. (2017). Sustaining screening, brief intervention, and referral to treatment (SBIRT) services in healthcare settings, Addiction, 112, (supp 2), 92-100.

Vendetti, J., Gmyrek, A., Damon, D., Singh, M., McRee, B. & Del Boca, F. (2017). Screening, brief intervention, and referral to treatment (SBIRT): implementation barriers, facilitators, and model migration. Addiction, 112 (supp 2), 23-33.

Williams, E.C., Johnson, M.L., Lapham, G.T., Caldiero, R.M., Chew, L., Fletcher, G.S., et al. (2011). Strategies to implement alcohol screening and brief intervention in primary care settings: A structured literature review. Psychology of Addictive Behaviors, 25, 206-214.

Zatzick, D., Donovan, D.M., Jurkovich, G., Gentilello, L., Dunn, C., et al. (2014). Disseminating alcohol screening and brief intervention at trauma centers: a policy-relevant cluster randomized effectiveness trial, Addiction, 109, 754-765.

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